Healthcare-seeking behavior for children aged 0–59 months: Evidence from 2002–2017 Indonesia Demographic and Health Surveys

Background and objective Healthcare-seeking behavior for children is crucial for reducing disease severity. Such behavior can improve child health outcomes and prevent child morbidity and mortality. The present study sought to analyze the determinants of mothers’ engagement in healthcare-seeking behavior for children with common childhood diseases, focusing on mothers of children aged 0–59 months in Indonesia. Methods This cross-sectional study comprised a secondary data analysis using the 2002–2017 Indonesia Demographic and Health Survey (IDHS) databases. We included all women surveyed aged 15–49 years old who had children under five years of age. We weighted the univariate, bivariate, and multivariate logistic regression analysis of healthcare-seeking behavior for children aged 0–59 months. Results We analyzed data for 24,529 women whose children were under five years of age at the time of survey. Common diseases, such as diarrhea, fever, and acute respiratory infection (ARI) were the most frequently cited reasons for healthcare-seeking behavior. During 2002–2017, the proportion of mothers seeking healthcare for their children with diarrhea increased from 67.70% to 69.88%, that with fever increased from 61.48% to 71.64% and that ARI increased from 64.01% to 76.75%. Multivariate analysis revealed that child’s age, child’s birth order, mother’s education, ability to meet expenses, distance to nearest healthcare facility, wealth index, place of residence, and region of residence, were significantly associated with healthcare-seeking behavior. Conclusion Various individual and environmental-level factors influence healthcare-seeking behavior for childhood diseases. Available, accessible, and affordable health service facilities are recommended to assist socio-economically and geographically disadvantaged families.


Introduction
Over the last two decades, significant progress has been made in regard to reducing morbidity and mortality worldwide [1]. Globally, mortality rates for children under five years of age have decreased, falling from 76 per 1,000 live births in 2000 to 39 per 1,000 live births in 2018 [2]. However, most deaths among children under five occur in developing countries, such as those in Sub-Saharan Africa and Central and Southern Asia. In 2019, countries from these regions accounted for approximately 80% of the 5 million deaths of children aged under five occurring globally [3]. Therefore, to achieve the United Nations Sustainable Development Goal of reducing the child mortality rate to �25 deaths per 1,000 live births by 2030, developing countries should be specifically targeted [4]. Notably, in most cases of deaths among children under five years of age the causes are either treatable or preventable, particularly when diagnosis and/or treatment occurs early [1].
Indonesia has approximately 270 million people, including up to 22 million children aged under five years, and has up to four million childbirths per year [5]. Despite a reduction from 97 deaths per 1,000 live births in 1991 to 32 deaths per 1,000 live births in 2015, Indonesia's mortality rate for children under five years remains higher than that of other Southeast Asian countries [6,7]. Therefore, to prevent and reduce morbidity and mortality among this age group, it is essential that children receive appropriate and timely healthcare.
In Indonesia, acute respiratory infections (ARIs), diarrhea, and fever are recognized as the primary causes of morbidity and mortality among children under five years of age [8]. Indonesian national statistics have reported that approximately 4%, 14%, and 31% of children under five experience ARI symptoms, diarrhea, and fever, respectively [9,10]. Notably, these percentages are similar to those recorded in countries deemed by the United States Agency for International Development to be priority areas: in countries in Western, Central, Eastern, and Southern Africa, 5.8%, 15.5%, and 23.4% of children under five years of age experience ARI symptoms, diarrhea, and fever, respectively [11]. Indonesian national data report that approximately 8% of children under five who experience ARI symptoms do not receive healthcare [9]. Studies have revealed that parents' healthcare-seeking behaviors for their sick children has an important impact on treatment quality and the speed of the reduction of morbidity and mortality in children [11]. Furthermore, a systematic review showed that caregivers' ability to recognize when healthcare is needed to treat common childhood illnesses is also critical for reducing child mortality in low-and middle-income countries [12]. Failure of caregivers and parents to seek appropriate care for sick children contributes to the high rates of under-five mortality in countries such as Ghana, Kenya, and Zambia [13].
Healthcare-seeking behavior is an effort to seek healthcare or medical treatment from healthcare providers in healthcare facilities [6]. Numerous complex factors influence parents' decisions regarding whether to access healthcare for children under five years, including cultural beliefs and perceptions of disease, the perceived severity of the disease and the efficacy of treatment, area of residence (urban/rural), gender, household income/household wealth quintile, treatment costs, child's age, household size, mother's age, and mother's education level [14,15]. Among caregivers in Ghana, Kenya, and Zambia, education level, residence, and wealth index, as well as the distance to the nearest healthcare facility, have been shown to influence their decisions to seek treatment [13].
In the Indonesian setting, there are disparities between urban and rural areas regarding the quality and availability of healthcare facilities and services. Ensuring health-service equity within health systems and adequate utilization by parents and families remain the main challenges [16]. However, research on factors that influence healthcare-seeking behaviors among mothers in Indonesia, especially for children aged 0-59 months, remains scarce. The present study aimed to analyze the determinants of healthcare-seeking behaviors by mothers on behalf of their under-five children who have contracted common diseases. The current study, using nationally representative data on Indonesian households' healthcare-seeking for the period of 2002-2017, may expand understanding of such determinants. This study provides vital insights into healthcare-seeking behavior, and key information that may guide policymakers in the area of maternal and child health.

Design and data source
This present study comprised a secondary data analysis of nationally representative data from the Indonesian Demographic and Health Survey (IDHS) for the period of 2002-2017. The IDHS is a cross-sectional survey that is typically conducted every five years. The survey uses standardized international questionnaires and rigorous methods for data collection. Ethical approval for the IDHS was granted by the Inner-City Fund (ICF) OCR Macro (number 45 CFR 46) and the National Board Review of the Ministry of Health, Republic of Indonesia, and all participants provided informed consent prior to the study. Trained fieldworkers collected data through face-to-face interviews with women aged 15-49 years who had children aged 0-59 months at the time of the survey. A women's questionnaire and a household questionnaire were used. The survey design employed a two-stage stratified cluster-sampling approach to ensure the representativeness of the data. The first stage of sampling was the selection of several census blocks using a probability proportional to size approach. In the second sampling stage, a random sample of ordinary households was selected from the list of census blocks [9]. The IDHS provides rich information and up-to-date estimates of fundamental demographic and health indicators, with a 98% response rate at the household level. Incomplete or unavailable data were excluded from the database. The study population was all women aged 15-49 years who had children under 5 years (0-59 months). All women aged 15-49 years were eligible for inclusion in the study. The final unit data comprised 24,529 mothers aged 15-49 who had children under five years (0-59 months). ICF International approved the use of the data for research purposes.

Variables
Dependent variable. In this study, the outcome variable was mothers' engagement in healthcare-seeking behavior for their children aged 0-59 months. Engagement in healthcareseeking behavior was categorized as "no" or "yes." For this analysis, "no (healthcare)" was defined as mothers seeking care from non-healthcare professionals or untrained health workers, or not seeking any healthcare, for their children under five. Meanwhile, "yes (health care)" was defined as mothers seeking care from healthcare workers or qualified and professional healthcare providers, such as doctors, nurses, and midwives in any healthcare facility, including hospitals, clinics, healthcare centers, and private healthcare practices. Independent variable. In this study, independent variables included child factors such as child's age, child's gender, presence of diarrhea, fever, and/or ARI symptoms; maternal and paternal factors such as birth order, mother's and father's ages, mother's and father's education level and occupations, and area of residence; and socioeconomic/household factors such as whether the family were able to meet expenses, distance to the nearest healthcare facility, whether the family was covered by health insurance (yes/no), and household wealth index. Child age was classified into three categories: "< 12 months," "12-36 months," and "> 36 months," respectively. The sex of each child was categorized as "female" or "male." "Yes" and "no" answers were used to determine whether the children had diarrhea, fever, and/or ARI symptoms. Birth order was classified into three categories: "1st," "2 nd -3 rd ," "�4th." Parental education was classified into four categories: no education, primary education, secondary education, and higher education. Maternal age was categorized into three categories: "15-24," "25-34," and "35-49," while paternal age was categorized into four categories: "15-24," "25-34," "35-49," and "� 50". Parental occupation was classified as "working" or "not working." Several indicators were used to determine household factors. Having enough money to meet expenses and the distance to the nearest healthcare facility were set as either "a big problem" or "not a big problem." Health insurance coverage was categorized into two categories: "no" and "yes." Following the DHS guidelines [17], families' socioeconomic status was calculated using the household wealth index, and categorized into five classifications: "poorest," "poor," "middle," "richer," and "richest." Factors associated with area of residence included place and region of residence. Place of residence was classified as "urban" or "rural," while region was classified as "Eastern," "Central," or "Western" Indonesia, which represent the three primary geographical regions in Indonesia. The western region comprises Aceh, Bengkulu, Jambi, Lampung, North Sumatra, Riau, South Sumatra, West Sumatra, Riau, Bangka Belitung Islands, Banten, Jakarta, West Java, Central Java, Special Region of Yogyakarta, East Java, West Kalimantan and Central Kalimantan; the central region comprises South Kalimantan, East Kalimantan, North Kalimantan, North Sulawesi, Gorontalo, Central Sulawesi, West Sulawesi, South Sulawesi, Southeast Sulawesi, Bali, West Nusa Tenggara, and East Nusa Tenggara; and the eastern region comprises Maluku, North Maluku, West Papua, and Papua [18].

Statistical analysis
Data were analyzed using STATA version 16 (Stata Corporation, College Station, Texas, USA). We calculated frequencies, proportions, and odds ratios (ORs) with 95% confidence intervals (CIs). We weighted the univariate, bivariate, and multivariate logistic regression analyses of mothers' healthcare-seeking behaviors for their children aged 0-59 months. Chi-square statistical test and logistic regression was employed to examine the determinants of mothers' engagement in healthcare-seeking behavior for children with common childhood diseases. For data from the four survey rounds, each round was equally weighted. Weighting was performed to consider the complex nature of the IDHS data, while the "svyset or survey estimation" command was used to adjust for the survey sampling method [19,20]. The primary sampling unit or cluster variable, the stratification variable, and the weight variable were the three essential information to apply the complex sample design [20]. A likelihood ratio test was used to determine whether a factor was included in the model. A p-value of < 0.05 was interpreted as indicating statistical significance.

Respondent characteristics
A total of 24,529 mothers with children under five years of age were included in the study. Table 1 shows the respondents' characteristics. Overall, 66.45% of the mothers had sought PLOS ONE healthcare for their children. According to the results, in the two weeks preceding the survey 28.56% of the children had experienced diarrhea, 68.86% had experienced fever, and 18.1% had shown ARI symptoms. Of the total children, 58.70% were aged 12-36 months, 51.98% were male, and 51.24% were 2 nd or 3 rd children. Over half of the mothers and fathers had completed secondary education. Half of the mothers (49.68%) and almost all of the fathers (99.06%) were working. Furthermore, most respondents (79.80%) reported no great difficulties meeting expenses and no great difficulties regarding the distance to the nearest healthcare facility (86.98%). Over half of the respondents (53.46%) were not covered by health insurance. In terms of household wealth index, 21.96% of the respondents were classified as the poorest. In addition, over half of the respondents (53.70%) were from rural areas, and most respondents (79.61%) were from Western Indonesia. The healthcare-seeking behaviors of the mothers are shown in Fig 1. The proportion of mothers who sought healthcare when their children had diarrhea increased from 67.70% in 2002 to 69.88% in 2017. Similarly, the proportion of mothers who sought healthcare when their children had a fever increased from 61.48% in 2002 to 71.64% in 2017. An increase was also observed among mothers who sought healthcare when their children had ARI symptoms, rising from 64.01% in 2002 to 76.75% in 2017.

Bivariate analysis
The results of bivariate analysis are shown in Table 2. This analysis revealed that child's age, birth order, mother's education level and occupation, husband's education level, ability to meet expenses, distance to the nearest healthcare facility, household wealth index, and place and region of residence were significantly associated with mothers' engagement in healthcareseeking behavior. Furthermore, significant associations with mothers' engagement in healthcare-seeking behavior were also observed for children who experienced fever, diarrhea, and ARI symptoms. However, child's sex, mother's age, husband's age and occupation, and healthinsurance coverage were not significantly associated with mother's engagement in healthcareseeking behavior. Based on the data, mothers who have children aged <12 months are more likely to seek healthcare services (OR = 1.30; 95% CI = 1.14-1.47) than mothers who have children aged 12-   In addition, household socioeconomic factors were found to be significantly associated with healthcare-seeking behaviors. For example, mothers with secondary-level education had 1.35-times higher odds of seeking healthcare (OR = 1.35, 95% CI = 1.01-1.81), households in the richest quintile had 1.78-times higher odds (OR = 1.78; 95% CI = 1.48-2.13), and households that had no difficulties meeting expenses had 1.28-times higher odds (OR = 1.28; 95% CI = 1.14-1.44). Meanwhile, the findings revealed that families with no problems regarding the distance to the nearest healthcare facility had 1.34-times higher odds (OR = 1.34; 95% CI = 1.18-1.53) of seeking healthcare for children under five.

Multivariate analysis
Moreover, households' demographic factors, including place and region of residence, were determined to be associated with engagement in healthcare-seeking behaviors for children aged 0-59 months in Indonesia. For example, respondents who lived in rural areas had 1.24-times higher odds of engaging in healthcare-seeking behaviors than were respondents who lived in urban areas. Additionally, respondents who lived in Eastern Indonesia had 1.27-times higher odds than those who lived in Western and Central Indonesia.

Discussion
Considering the relatively high under-five mortality rate in Indonesia, the present study aimed to analyze the determinants of mothers' engagement in healthcare-seeking behaviors for children under five. Using nationally representative data for 2002-2017, we explored various factors, including socioeconomic and demographic factors, related to mothers' engagement in healthcare-seeking behaviors. Our findings showed that the presence of symptoms of childhood diseases, such as diarrhea, fever, and ARI, significantly affect the likelihood of mothers in Indonesia engaging in healthcare-seeking behaviors for their children. This study also revealed

PLOS ONE
that child, socioeconomic, and demographic factors, such as child's age, ability to meet expenses, accessibility of healthcare facilities, wealth index, and place and region of residence, were significantly associated with engagement in healthcare-seeking behavior.
Our study found that mothers of children with fever and/or ARI symptoms are more likely to seek healthcare services than mothers of children who do not experience these common childhood diseases. Previous studies have revealed that caregivers of children who experience ARI symptoms are more likely to seek healthcare for their child (70.4%) when compared to those of children who experience fever (68.5%) and children who experience diarrhea (63.3%), respectively [11]. Consistent with these findings, other studies conducted in developing countries have reported that children under five who have fever and ARI symptoms are more likely to be treated at healthcare facilities, whereas those with diarrhea are usually initially treated at home [21,22]. Children with diarrhea may be treated effectively at home by caregivers through oral rehydration and zinc supplements; in contrast, ARI symptoms and fever indicate severe disease and vulnerability. Therefore, children who experience these latter symptoms require healthcare from professional providers and immediate antibiotic treatment. Enhance the awareness and skill of mothers in seeking health care for the sick children is needed.
We found that mothers who had children aged <12 months were more likely to seek healthcare than mothers who had older children (>36 months). Similar findings have been obtained in previous studies, with some studies reporting that mothers of older children are less likely to seek healthcare than those of younger children [15,22,23], and other studies reporting that mothers of children under 12 months of age are more likely to bring their children to healthcare facilities and obtain medical treatment than those with children aged over 12 months [21,[24][25][26]. A possible reason for this is the vulnerability of younger children aged <12 months due to their immature immune systems and relatively high risk of infection from peers.
Our study found that mothers are more likely to seek healthcare for their first child than their second or third children. Possible reasons for this include the fact that one's first child may be more prone to illness, and novice mothers may have incorrect conceptions regarding child health. Notably, an earlier study reported that older children receive less attention in regard to healthcare-seeking because of their maturity [27]. Commonly, mothers pay more attention to and have greater awareness of their first child's health. Once the first child is diagnosed with an illness, mothers tend to take immediate action to seek healthcare. Mothers with two and three children are likely to have more experience; thus, they are less likely to seek medical attention for problems regarding their children's health. Routine visits to health facilities need to be scheduled to prevent illness in children.
We found that women with secondary education are more likely to seek healthcare for their children than are those with no educational background. Thus, mothers' knowledge levels may play a role in their decisions whether to use the healthcare system and whether to delay receiving professional care. This is consistent with other findings for low-and middle-income countries, which have indicated the role of women's education in regard to their engagement in healthcare-seeking for their children [24,28,29]. Some study also found that women with higher levels of education are more likely to seek health care services for their children [30,31]. Continuous effort to increase the access into education especially for Indonesian women is crucial in the long run.
The present study showed that mothers who reported that meeting expenses was not a big problem were more likely to seek healthcare for their children. The role of difficulty meeting expenses in this regard has been reported in a previous study, which stated that, if money is a notable issue for families, children who have fever and coughs are less likely to receive healthcare [32]. Notably, in Ethiopia, where healthcare is offered at minimum cost in rural areas, the additional costs associated with transportation and treatment can create difficulties for households [32]. In Indonesia, a national health insurance system (NHI) has been implemented across the country; however, inequalities remain, particularly in regard to low-income families, informal workers, and families with children under four years of age [33]. NHI membership coverage data for 2016 shows that only about 63% of Indonesian people have NHI [34]. Our study results also show that more than half do not have health insurance. Thus, families' financial status could affect their decisions to seek healthcare and travel to healthcare facilities.
Furthermore, this study revealed that mothers who reported that the distance to the nearest healthcare facility was not a big issue were more likely to seek healthcare for their children. This finding is supported by those of previous studies conducted in other countries [13,15,35]. Distance to a healthcare facility might be a common influencing factor underlying mothers' engagement in healthcare-seeking behaviors as a result of the efforts and transportation costs required to reach healthcare facilities. Although public-health facilities are available in each local community across Indonesia, empirical evidence has revealed that distance to healthcare facilities remains a significant challenge for obtaining healthcare [36]. Especially in the context of Indonesia, which is the largest archipelagic country in the world, this has resulted in uneven access to roads and transportation to health facilities in all regions.
This study found that richer households are more likely than poorer households to seek healthcare at healthcare facilities. This finding is consistent with those of other studies that have shown that more affluent families, when compared to low-income families, are more likely to obtain medical treatments for their children [24,36,37]. Thus, it is apparent that wealth index plays an essential role in mothers' engagement in healthcare-seeking behavior [24]. A possible reason for this is that households with greater incomes can afford to pay for health care and medical insurance [38], making them more likely to bring their children to medical facilities. Meanwhile, parents from the poorest quintiles are likely to experience more daily life burdens, making it more difficult to find the money to seek healthcare for their children. In addition, traditional medicine and self-medication are still prominent in Indonesian culture, such as making traditional herbal medicine and performing massage to cure illness [39]. Some of these traditional treatments were chosen because they are low cost and almost never require payment, making them more accessible to poorer households.
Our study found that place and region of residence are associated with mothers' engagement in healthcare-seeking behaviors for children aged 0-59 months in Indonesia. Mothers who live in rural areas are more likely to seek medical care for children than are mothers who live in urban areas. This finding is also consistent with those of other studies, which have shown that rates of care-seeking are higher in rural areas than in urban areas [13,40]. A possible reason for this is that mothers in urban areas have better health conditions and nutrition, which influences the nutritional status of their children and reduces the risk of childhood diseases. Another possibility is that mothers who live in urban areas assume that they have adequate knowledge and skills for managing common childhood diseases, which could, therefore, reduce their likelihood of seeking healthcare. A qualitative study conducted in urban areas in Indonesia also stated that the majority of families prefer traditional ways of caring for their sick children, such as scraping with shallots and other traditional medicines. In Indonesia there is also a spiritual belief against the prohibition of the use of medical treatment [41,42].
Additionally, mothers living in Eastern and Western Indonesia were found to be more likely to seek medical care for their children than mothers living in Central Indonesia. The western region of Indonesia has more developed regions than the eastern and central regions, with the latter two regions being generally known as underdeveloped areas with significant poverty rates and lower living standards when compared to the western region [43]. Empirical evidence shows that socio-economic development, including transportation, roads, and healthcare facilities, is not evenly distributed throughout Indonesia, especially in the eastern region [44][45][46]. Further, the majority of doctors in Indonesia (57.4%) are located on Java, which is part of the western region [47]. Studies have indicated that easy access to healthcare facilities and adequate numbers of healthcare workers can increase mothers' likelihood of seeking healthcare for their children [48,49]. This may be one of the reasons mothers who live in the western region of Indonesia show greater healthcare-seeking behaviors for their children than those in the central region. Surprisingly, however, our findings show that mothers who live in the eastern region have the highest tendency to seek healthcare services for their children. People living in eastern Indonesia experience a much higher rate of disruptive morbidity than those living in western Indonesia [50]. In 2004, almost one-fifth of people living in eastern Indonesia experienced disruptive sickness, causing them to use healthcare facilities more often [51]. Although, in Indonesia, as an archipelagic country, geographical constraints can impact the availability and affordability of health services for families, especially those in the Eastern region, based on our findings mothers in this region still prioritize seeking health for their children.
To our knowledge, this study is the first to use data from the 2002-2017 IDHS to explore the determinants of engagement in healthcare-seeking behaviors among mothers in Indonesia for children aged under five. Our study examined various factors affecting mothers' engagement in healthcare-seeking behavior for children of this age group. However, this study, nevertheless, contains several limitations. This study used a cross-sectional method and, therefore, causality could not be determined. Moreover, although the analysis for this study fully utilized for the available data from the IDHS, the dataset featured limited coverage of predictor variables; thus, the predictor factors were not analyzed because of unavailability in the dataset. In addition, the survey was based solely on mothers' responses (self-reported) two weeks preceding the study; therefore, recall bias may be present. Despite these limitations, however, our study has a strength in that it used a dataset featuring the most recent nationally and provincially representative data obtained through a survey that had a high response rate (>95%). Moreover, these data were nationally and internationally standardized. The uniqueness of this study in terms of healthcare seeking practices of mothers for their sick children was mothers remains at the forefront of care. Empowering mother with supportive resources especially at the community level contribute to the positive impact on children's health outcomes in Indonesia.

Conclusions
Several factors are related to mothers' engagement in healthcare-seeking behavior for children under the age of five in Indonesia. Symptoms of common childhood diseases, such as diarrhea, fever, and ARI, are significantly associated with such engagement in healthcare-seeking behaviors. Additionally, child's age, birth order, mother's education level, ability to meet expenses, distance to the nearest healthcare facility, wealth index, and place and region of residence were determined to significantly influence such engagement. Our findings reveal that it remains necessary to promote public awareness of childhood diseases and the importance of seeking healthcare services when children are ill. Moreover, our study has policy implications: we suggest that, for families who are socioeconomically and geographically disadvantaged, healthcare facilities be made readily available, approachable, and affordable. Moreover, regarding future research, several factors influence the barriers and facilitators healthcare professionals experience when seeking to deliver healthcare services; therefore, qualitative research should be undertaken to determine the health-service preferences of mothers and families, as this information could help address such barriers.